To our knowledge, this article is the first to present an anamnestic self-assessment questionnaire that aims at increasing the safety of surgical patients and to discuss the advantages of structured and standardized preoperative risk assessment.
The surgical complications described in the medical literature may not reflect their true incidence due to publication bias. [10] Setting inaccurate standards for the medical professionals raises patients’ expectations and, consequently, patients are more likely to file a malpractice lawsuit. Data from the Medical Professional Liability Association suggest that claims and the compensation payouts in plastic surgery are ever increasing.[11] On the other hand, the analysis of published scientific literature and the review of malpractice lawsuits allow us to continuously improve patient care.[12] Although the reported case did not result in litigation, it illustrates the added value for the assessment and documentation of surgical risk factors.
The intraoperative application of the widely accepted World Health Organization Surgical Safety Checklist (WHO SSC) reduced the mortality rate by 7 % and inpatient complications about 4% within the first 30 postoperative days. [11] In contrast to surgical safety checklists, including the WHO SSC, which were elaborated for the intraoperative period, [12] the multidisciplinary Surgical Patient Safety System (SURPASS) is a surgical safety checklist that accompanies the surgical patient from the admission until the discharge.[12] [13] This checklist has been shown to prevent 29% of the cases that lead to irreversible disability and 40% of the events that resulted in death. [12] The combination of both WHO SSC and SURPASS checklists may lead to a lower rate of complications during the hospital stay, urgent re-intervention, and re-admissions. [13]
Nowadays, physicians struggle to provide the best patient care and involve patients in the decision-making process, while complying with the time constraints [14] and the limited resources made available by the economy-driven society.[15] However, meticulous patient anamnesis and preoperative evaluation helps tailor the treatment strategy to every patient.[16]
The reliability and accuracy of the anamnesis may be adversely impacted by various factors. Patients may reveal imprecise information either consciously, due to embarrassment, especially towards authority figures, such as doctors; or unconsciously, as the order and formulation of the questions may modulate the interpretation of the same.[17] Besides, other elements affect the accuracy of the collected anamnestic information, for instance, age, educational level, and professional background.[16]
Written self-assessment questionnaires not only improve the efficiency of the physician’s time,[18] but also minimize the misreporting of anamnestic facts in comparison to a verbal patient interview.[17] They have been shown to be a comprehensive and reliable tool to record the patients’ anamnesis.[18] A study analyzed the effectiveness of a structured self-assessment questionnaire in a digitalized form [16] and concluded that it can benefit both patients and medical professionals, improving the quality of the patients’ records.[16]
A simply formulated, meticulous, and well-structured self-assessment questionnaire is a fundamental pre-surgical evaluation tool to minimize the risks involved in the surgical procedure and protect surgeons from malpractice lawsuits. Knowledge of the test-retest reliability and validity certainly adds to the quality of a clinical questionnaire but requires considerable time and effort and should not prevent the use of a systematic risk assessment questionnaire.